Lactobacillus paracasei Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis and Review of the Literature

Abstract

We describe the first case of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis due to Lactobacillus paracasei. It occurred in a 65-year-old patient with recurrent episodes of peritonitis while he was receiving a prolonged course of intraperitoneal vancomycin. L. paracasei should be considered in the differential diagnosis of pathogens in CAPD-related peritonitis, especially in patients receiving prolonged vancomycin or glycopeptide treatment. CASE REPORTA 65-year-old diabetic male with end-stage renal disease commenced continuous ambulatory peritoneal dialysis (CAPD) in March 1999. In July 2001, he first reported abdominal discomfort and cloudy dialysate but no fever. Physical examination demonstrated a benign abdomen with a normal-appearing catheter exit site. Peritoneal fluid dialysate was hazy in appearance (white blood cell [WBC] count of 2,040/l, with 96% segmented neutrophils). Therapy with intraperitoneal aztreonam and vancomycin was initiated. Peritoneal fluid culture grew methicillin-resistant Staphylococcus haemolyticus. The patient finished a 2-week course of vancomycin with good results. Shortly thereafter (at the end of August 2001), he developed another episode of CAPD-related peritonitis (peritoneal fluid WBC count of 500/l, with 90% segmented neutrophils). This time, the peritoneal fluid Gram stain showed gram-positive cocci in chains and the culture grew alpha-hemolytic streptococcus species, not enterococcus species. He was given an additional 4 weeks of intraperitoneal vancomycin, during which his abdominal complaints and peritoneal fluid pleocytosis worsened (WBC count increased to 3,200/l, with 80% segmented neutrophils, 5% lymphocytes, and 15% monocytes). Peritoneal fluid cultures during this period revealed diphtheroids and alpha-hemolytic streptococcus species, not enterococcus species. Due to nonclearing of the peritoneal dialysate and ongoing abdominal discomfort, vancomycin was stopped and he received oral levofloxacin and intraperitoneal ceftriaxone, with mild improvement. In early October 2001, the peritoneal fluid analysis showed a WBC count of 784/l (97% segmented neutrophils and 3% monocytes), and culture grew methicillin-resistant Staphylococcus simulans; he was restarted on intraperitoneal vancomycin and continued oral levofloxacin. Two weeks later, on 18 October 2001, the peritoneal fluid analysis revealed a WBC count of 126/l, with 21% segmented neutrophils, 16% lymphocytes, 61% monocytes, and 2% eosinophils, and culture grew a Lactobacillus species, later identified as Lactobacillus paracasei. Antibiotics were stopped at that point, with the assumption that the mild cloudy dialysate effluent represented chemical peritonitis. However, he continued to have abdominal discomfort and started becoming hypotensive. Intraperitoneal vancomycin and aztreonam were started. He was later admitted to the hospital. Repeat peritoneal fluid analysis (9 November 2001) revealed a WBC count of 325/l (21% segmented neutrophils, 16% lymphocytes, 61% monocytes, and 2% eosinophil...

Molecular Analysis and Clinical Significance of Lactobacillus spp. Recovered from Clinical Specimens Presumptively Associated with Disease

“…In this retrospective study of laboratory records between 1998 and 2013 at the Veterans Affairs medical centers in Houston, TX, and Seattle, WA, we identified a total of 107 Lactobacillus isolates that were found in clinical specimens in the context of presumed pathogenic potential (e.g., recovered as the single/predominant isolate from a sterile site or at Ն10 5 CFU/ml from urine) and could be assigned unambiguously to a species by 16S rRNA sequencing. Four strains were sent from other Veterans Affairs medical centers for identification (3). All of the available isolates were included in the study, with one exception; since isolates from male UG specimens were the most numerous, a convenience sample of about 30% of the total was chosen to match the number of female UG specimens.…”

“…Biochemical characteristics are insufficient to allow reliable identification of lactobacilli to the species level, making molecular diagnostic approaches such as 16S rRNA gene sequencing necessary (2). Because lactobacilli range in size and shape, even presumptive genus identification can be difficult, as lactobacilli may be confused with other Gram-positive, catalase-negative organisms such as Streptococcus (3,4) and Leuconostoc (5). Since lactobacilli rarely cause disease, many laboratories choose not to determine the species and simply report the isolated organism as "Lactobacillus sp."…”

“…Apart from the known pathogenic association between lactobacilli and dental caries, several clinical case reports describe the opportunistic nature by which lactobacilli cause disease. Reported infections include endocarditis, bacteremia, peritonitis, and localized soft-tissue infections (1)(2)(3)(6)(7)(8). Most infections caused by Lactobacillus spp.…”

Spontaneous Bacterial Peritonitis due toLactobacillus paracaseiin Cirrhosis

“…Lactobacillus species are rarely implicated in spontaneous abdominal infections. Previous case reports describe secondary Lactobacillus peritonitis in the setting of peritoneal dialysis, recent intra-abdominal surgery, or gastrointestinal perforation [ 2 – 6 ]. Spontaneous Lactobacillus peritonitis in the absence of these risk factors is exceptionally rare and has exclusively been reported in severe decompensated cirrhosis with ascites [ 2 , 7 ].…”

Two Cases of Peritonitis Caused byKocuria marinain Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

“…The most common causative organisms are gram-positive bacteria, particularly Staphylococcus aureus and coagulase-negative staphylococci, which are part of the normal skin flora (10,12). The peritonitis is usually diagnosed on the basis of cloudy effluent and the effluent cell count.…”